30 April 2006

29 April 2006

Never had too much use for the thing -- the rich and famous get together to bask in how great they all are. Kind of like the Oscars, only without the glamour and style, and with much uglier people. Apparently, Steven Colbert killed, though the Lord High Commander was not amused, alas.

Money Quote:

"One of the great things about President Bush is that he sticks to his principles. When the president decides something on Monday, he still believes it on Wednesday - no matter what happened Tuesday."

Okay, I can't resist -- one more:

[Colbert] attacked those in the press who claim that the shake-up at the White House was merely re-arranging the deck chairs on the Titanic. “This administration is soaring, not sinking,” he said. “They are re-arranging the deck chairs--on the Hindenburg.”

28 April 2006

The most recent CNN Poll has W down to 32% approval. I'm chilling a magnum of champagne for when he finally cracks 29%. Not that it's significant, it's just a milestone, like when the Dow broke 10,000.

It's kind of interesting to see the slope of Bush's ratings, from the meteoric spike at 9/11, steadily down until the invasion of Iraq, with a small spike there, and a continued downward trend with a small uptick during the campaign, and then back on its predetermined course. It's so linear it almost makes you wonder whether it could reach zero if he stayed in office long enough. Nah, it would probably get asymptotic at the end.

We staff two sites at the facility where I work. There is one main hospital which is very high-acuity and receives a ton of ambulance traffic, and a satellite facility which has been marketed to the community as more of an urgent-care center, and adjoins our Women's and Children's hospital.

So I worked the other night at the main facility. I saw a lot of weak and dizzy old folks and septic nursing home dumps transfers. The median age of my patients that night was 83 years old, with a maximum of 102.

Tonight I am working at the satellite ED. The median age today has been 8 (having a bimodal distribution with peaks at 16 months and 33 years), with a minimum age of 9 days.

Different worlds. Both get tiring if you do nothing but, so I am glad I have both, for variety. But very very different worlds.

26 April 2006

The Commonwealth Fund Has released a report (hat tip: The Washington Monthly) which looks at the "Changing Face of the Uninsured." Striking facts: over 40% of moderate-income adults are un- or under-insured, and over half of low-income adults were so afflicted. The noteworthy thing is that the proportion of moderate and even middle-income adults without insurance has increased by more than half in just four years. As a business manager who sees what the total premium cost has done over the past few years, I am not surprised. Even employing doctors, who are high-income by any definition, it's been a struggle to meet the rising costs of the health care. No surprise that businesses on low margin or employees of more modest means are obligated to do without.

For those who, like me, ejnoy pretty pictures:

Also note that the total un-insured and under-insured fractions are much higher than estimated elsewhere: 18% and 28%, or 51 million uninsured and 81 million Americans underinsured. The best alternative figures I have seen put it more like 46 million and 61 million. I have no idea which might be more accurate, but either way you look at it, it's a butt-ton of people who can't get good health care. So instead, they come to see me:

More than twice as often for their chronic problems, and at a higher cost.

I love sitemeter -- just the map function alone is worth its existence, but I also like seeing what pages folks are coming from. Well, recently I have had a spike in hits, and the referrals page seems to be getting listed on search pages for those who search for the phrase "penis guillotine."

Who knew such an item was in high demand? Someone notify the venture capitalists!

I was asleep and having some random dream when a little transparent icon popped up with a picture of our office manager's face and a text message below it regarding some problem with the credentialling of one of our new hires. I thought "Oh no, she's figured out how to instant message directly into my brain and even into my dreams. I'll never be able to get away from her now."

Her IM nickname, BTW, was the latin word for "Blondie," but I can no longer recall what it was.

18 April 2006

Doctors in private practice fear a loss of autonomy with a single-payer system. After being in the private practice of family medicine for 8 1/2 years, I see that autonomy is largely an illusion. Through Medicare and Medicaid, the government is already writing its own rules for 45% of the patients I see.

The rest are privately insured under 301 different insurance products (my staff and I counted). The companies set the fees and the contracts are largely non-negotiable by individual doctors.

The amount of time, staff costs and IT overhead associated with keeping track of all those plans eats up most of the money we make above Medicare rates. As it is now, I see patients and wait between 30 and 90 days to get paid. My practice requires two full-time staff members for billing. My two secretaries spend about half their time collecting insurance information. Plus, there's $9,000 in computer expenses yearly to handle the insurance information and billing follow up. I suspect I could go from four people in the paper chase to one with a single-payer system.

Why consumers should support it:

A single-payer system would increase access to care for the uninsured and the underinsured, including the working poor. It would lower total health costs, in part by replacing 50 different state Medicaid programs and umpteen insurers with one system. This approach has the potential to improve quality and lower costs by improving care for chronic illnesses such as diabetes, high blood pressure and heart disease.

Of course, nothing is going to happen for the next 1007 days. But I like the fact that this topic is getting attention, serious attention from both sides of the aisle. From Romney and the WSJ on the right, to Krugman and the pack on the left. And while I have soured a bit on the Massachutsets plan (see here for a great explication why), the fact that a right-wing presidential candidate championed a "universal" health plan will make it a lot harder for the wingnuts to demonize it as liberal big government.

07 April 2006

It's getting warm outside. That's the only explanation I can see for the fact that in the past two days I have sewn up three little boys between the ages of 5 and 10 years old who had sustained lacerations to their genitals.

Yeah, ouch.

Two were to the scrotum. They were both standard straddle injuries. One was from falling off a bike, the other from falling on ladder coming down from a treehouse. Standard kid stuff, really. Contusions and a small cut, four or five stitches. They boh managed to not injure the testicles at all. Whew.

The other was a sweet very very dirty little 5 year old who was peeing in the potty when the lid fell. Yeah, right on the pecker. A 2 cm laceration on the penis, transverse, right across the base. Not serious, really superficial, but one of those injuries which conjures up the mental image of a guillotine. [cringe] The poor kid -- will he ever have the courage to use the toilet standing up again?

But he was a trooper. He whimpered a little when I injected it with lidocaine. (Note to interns: without epinephrine!) But once it was numb, he didn't cry or squirm or anything. I was so relieved. I was expecting a rodeo ride trying to stich that damn thing up. I had considered sedating him. I didn't want it to be a more traumatic experience than it had to. But no, he took it better than many adults take stitches in . . . less sensitive places. Thank goodness. And he was polite enough to thank me and shake my hand after I was done.

04 April 2006

Okay, I've had two beers and am dehydrated from Karate, so my critical thinking skills are not at their best, and I am still sharp enough to be skeptical of anything Mitt Romney is associated with, but . . .

This is the sort of thing the nation needs, BADLY. Now it has a number of flaws on the face of it. It's not single payor. It works via coercion and the enforcement is fuzzy at best. The adverse selection incentive will still drive the poorest/sickest into the worst plans. It's not automatic universal coverage. So it's not perfect. But what's the saying? "Don't let the perfect be the enemy of the good."

This has some good features. It appears to create affordable insurance plans even for otherwise uninsurable folks. It subsidizes low income folks in a rational manner. It maintains co-pays even for low-income folks (keeping an element of personal responsibility in the system). I wonder where it fits in with Medicaid?

I'll need more details, I think, before I sign on as an enthusiast. But it's a great start, it's innovative, and if nothing else, should add fuel to the fire for a national solution.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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